Just a quick update for those following. We arrived in Baglung, which is about 80km west of Pokhara on Saturday about a half hour before the earthquake hit. We safely made our way into the road during the first tremor and stayed together with the locals. We are staying at a hotel that has both a new building and an older building and after that experience promptly agreed on a room in the new building. The subsequent night was tumultuous, but we made it through safely, with our earthquake plan in place. It takes us less than 30 seconds to get out to the courtyard of our hotel.

Last night was a much better night. We slept well and headed off to the hospital in the morning, where two women are being induced. The hospital has been our most welcoming yet! We really feel we’ll be able to get the hands-on experience we’ve been craving, as well as bringing some love and peace to the women here.

After lunch today, we find ourselves once again in the courtyard (which is our most favourite place in the daytime) observing as men from the community setup a little square, with bricks and tree branches, colorful metallic flags and sand. In broken English we found out that these are preparations for a wedding that is happening tomorrow! About 500 people are apparently attending! We are quite excited and planning to wear our fancy kurtas! This is such a lovely reminder that life must carry on. And that the people here feel strongly that the worst is hopefully over.

It’s been so lovely to chat with our loved ones over the last few days. We will hit 72 hours around noon tomorrow, which is when they will start moving patients back up into floors above the first in the hospital. I think once we make that milestone we will start to feel more like ourselves again.

Our love and prayers go out to those less fortunate. We are doing well and are so lucky to be where we are. Sending lots of love home. For those inclined, please keep praying and sending love and good thoughts. Our friends in Kathmandu at last check were doing okay.

Why was yesterday such a great day?

1. We had our first “sleep in” day – right up to 7:30am!

2. And then we awoke to Cathy peeking her head in our room and saying, “There’s a surprise outside!” What was the surprise? A total blue sky and the first clear view of the stunning Annapurna Range of mountains. We rushed up to the roof, giddy with anticipation, and were rewarded with amazing views of the massive mountains which have so far been covered by the clouds.

3. We had fun at Antenatal clinic at Gandaki Hospital, learning from the student nurses as they performed belly palpations and listened to fetal heart rates. Dozens and dozens of women were lined up and offered us welcoming smiles. It was good to be in the midst of pregnant women.

4. Our new placement in Baglung was approved! We’ll head out tomorrow.

5. We spent the afternoon at Lakeside and had our fave – Lassi’s.

6. We got our government approved letter to officially arrange our teaching workshop in Jomsom in early May.

7. We met Dharma Shila, a MIDSON member and nurse who will present the MIDSON portion of the workshop. She was so lovely and we look forward to getting to know her better. We are also glad to be working in collaboration with MIDSON for these workshops.

8. Our “peak” of the day: sitting in the little restaurant around the corner from our guesthouse showing Dharma Shila and Neelam (another MIDSON nurse) several videos (in Nepali language) about physiologic birth and watching for danger signs in newborns  to provide timely care. As soon as the other women in the restaurant heard the Nepali language they gathered around to watch too! It was so great. Three of the women who gathered were a grandmother, mother and daughter watching what good care immediately after birth could look like (and the videos are filmed in Nepal).

We head to Baglung tomorrow to attend births at a smaller hospital, with a supportive OB. Because it is quite rural, we may not have access to internet for at least a week. We’ll be adventuring, learning and are hoping to bring the midwifery way of birth to women in that community. Lucky for you, we will be keeping track of our thoughts and stories with pen and paper!

We’ll be back in Pokhara on May 2. And hope to get a few posts up upon our return…just in case you don’t hear from us in the interim.

In total, we spent 4 days in the Pokhara Gandaki Hospital. We observed for two days in labour and delivery, and spent two days in the antenatal clinic. While we have a LOT to write about, and much to think about because of this experience, we have also learned what we are made of.

All of the births we witnessed were very medicalized. Control by medicine seemed very important. It is far from birth as a psychosexual experience that I’ve been reading about in Sheila Kitzinger’s book, Birth and Sex (which at the moment, is also keeping me sane). In fact, it’s not even close to birth at home. Though to say I didn’t expect it wouldn’t be true – Cathy had briefed us on what birth was like at this hospital before we arrived. That said, seeing it in person is a lot different from hearing about it in anticipation.

The typical labour and birth at this particular hospital includes oxytocin induction (without prostaglandins first) or augmentation, labouring without support or pain medication in the first stage room (on benches, amongst 7 other women). Then, once full dilation is achieved, the woman is helped to the second stage room. There are three delivery tables in a room the size of our Midwifery Lab (for those who don’t know, it is small). The woman is put on the table, usually propped up (which is good), and instructed to push with contractions. Student nurses crowd each woman as she is pushing – with the other birthing women on tables in the room looking on in anticipation of their impending birth, or in relief of it being over.

Despite the use of oxytocin, fetal heart monitoring is done periodically with Pinard horns and fetoscopes. Once the head is visible, infiltration is conducted (if the woman protests the needle, then anaesthetic is not given) and an episiotomy is cut (without consent and with or without anaesthetic). With a few more pushes, the baby is born, placed swiftly on mom’s abdomen and wiped off. At the same time, the cord is immediately clamped and cut, and baby whisked off to the warmer. None of the babies we observed being born needed any resuscitation, and we were present for 7 births. Then the baby is bundled, handed off to a family member outside of the birthing unit, and the woman receives active management for the birth of the placenta.

Following the birth of the placenta, the women are sutured. They do infiltrate with lignocaine 2% diluted with sterile water, but don’t wait long enough for it to take effect or put in enough to adequately freeze the area being sutured (based on the squirming, screaming and heavy breathing of the women being sutured). During the time we were there, I found myself with two different women throughout the day, looking into their eyes, breathing with them, helping them maintain control over the pain of being sutured with inadequate anaesthetic. The nurses suturing don’t seem to connect the reaction of the woman to their handywork, which is very troubling, given that all the nurses are women themselves and this is a teaching hospital. Once the nurses finish suturing, the women are rolled off the table (as another woman is brought in) and directed to the postnatal room (of multiple women, babies and families). The whole process got us to thinking: if only the women weren’t cut, most wouldn’t need suturing, or would need very little, and would quickly be able to hop off the table with their babies and together head to the postnatal ward.

So, after watching this scene repeat itself 7 times, we decided we had had enough and needed to get ourselves to the nice part of Pokhara to decompress. We watched a particularly meaningful birth video from home (thank you Jessa!) and ordered some comfort food at our most favourite restaurant.

Maintaining control over our own emotions during such emotionally-charged moments has proven difficult, but very important. I can’t say I didn’t want to lose it multiple times over the course of that one day in labour and delivery. I also can’t say I didn’t choke back tears between births. This is so far from our norm and from the type of birth we wish for any of our clients. I am often left wondering how we got so lucky to be in Canada at a time when this sort of birth is foreign.

There is lots that needs to change based on these simple observations. Things that are as easy as reducing the number of students in the delivery room and inducing and augmenting labour only when medically indicated would be a good start. More difficult is encouraging system-wide change in order to comply with Nepali Health Policy, which includes immediate skin-to-skin, delayed cord clamping, restrictive episiotomy, and breastfeeding within the first hour.

However, what is most clear to me is how badly Nepal needs midwifery. The women of Nepal want midwives. In light of our experience in L&D, we took yesterday off to plan for a trip to an adjacent region that has fewer births, but is more open to change. In the evening, after our packing and debriefing, we hosted two maternity nurses at our guest house’s restaurant, discussed normal birth and showed several videos in Nepali about immediate postpartum care for mum and babe, and 8 danger signs in the newborn baby. What was remarkable was how intrigued each woman was! Our guest house owner, her mother and her daughter even tuned in as soon as we put the videos on. They locked all the doors to “keep the boys out!” It was so reaffirming to know that the work we are doing is important, and valued by the very women who have or will be accessing care.

And so, today, on the eve of our departure for another town, we find ourselves in tourist Pokhara once again to celebrate with lassis and tell our friends and family back home that despite the ups and downs of this journey, we are doing fine, and will continue striving to improve care for women in this part of the world.

Much love home.

I was sick yesterday (good ol’ whatchamacallit’s revenge….) so I missed our official first day on labour & delivery of Gandaki Hospital, a Western Region Referral Hospital (fyi – the levels of hospitals are: National Referral Hospitals, Regional Referral Hospitals, District Referral Hospitals, Primary Health Care Centres, and different levels of Health Posts.) I made up for it today though – by noon we had witnessed 7 births! We are still only allowed to observe at this point, but we are using this time to become familiar with the local practices and get to know the nurses and nursing students.

The birth environment here is so different than at home. Women labour in the “first stage room”, which has about 8 beds/benches. When they are fully dilated and ready to push they are brought into the delivery room which has three beds. The beds have rusty frames with black plastic cushioned tops that get wiped down between women. The walls are lined with supplies and there is a table in the corner where the nurses sit to record details from the birth.

The most shocking part (to me) of the delivery room was the number of students crowding around each woman as she pushes. At one point today I counted 18 student nurses – not including us! For three women! We are so accustomed to protecting women’s privacy during birth, and it feels unusual (and to be honest, a little uncomfortable) to see so many women crowding in to watch a woman birth, and stare in between contractions. The other shocking part is that all the women who birthed today received an episiotomy – some with analgesia, some without – but none were clinically indicated. The Nepali government policy is that episiotomies should be restricted to those cases that require it (ie. emergencies or with forceps). Unfortunately, this hospital (and many others we are told) does not practice according to updated guidelines, and every woman is cut. The women were pushing beautifully. Babies heart rates were fine. Jacquie took on the role of “suturing doula”, tending to women while their epi’s (as the nurses like to call them) were sutured. Four other aspects of labour care we would like to challenge are the fact that the nurses do not wait for restitution and pull on babies heads at birth, babies are not kept skin to skin with mom, breastfeeding does not happen within the first hour, and delayed cord clamping is not carried out.

We can’t wait until we are allowed to be “hands on” so we can demonstrate a more “hands off” delivery technique. We’re feeling pretty passionate about no episiotomies unless clinically indicated! But, babies were healthy. So that is great.

(from a few days ago! internet has been a bit sparse)

We’ve been eating a lot of starch here in Nepal – my fave! The most starchy so far? Our deep fried potato sandwich! It came to $0.35 each. We enjoyed “Joyous celebration” together to celebrate our good find, lol!

Cathy got the license she needed to preceptor us after a crazy rigmarole! She was sent all over the city tracking down signatures, documents, letters of invitation, and basically sent through numerous hoops – but she worked her way through them all and we are loving her kind persistence. We’re grateful, and we have now officially bought our bus tickets and we leave for Pokhara Sunday.

Emma arrived late on Wednesday night and joined us for our travels to come. It is so nice having her here. She has experience in Nepal and knows the area where we are staying well, so she has introduced us to restaurants that she loved when she was here last and has an intuitive sense of direction that none of us (except Cathy) possess, but all of us appreciate!

We leave for Pokhara tomorrow, and Cathy is quick to point out that we are not heading to the “known” Pokhara (it is known for being a very touristy destination) but the Nepali Pokhara, which like most of this country is a study in opposites. You see the most breathtaking kindness and joy in the unlikeliest areas, women dressed with care in beautiful colours against a stark backdrop, laughter and storytelling that will lift your spirits for days in places you wouldn’t think to enter. Yesterday this very amused little boy came running between Emma and I and looked me square in the face with the broadest grin and shook my hand. He just wanted to shake my hand. Then he bobbed along after someone who seemed to be his grandmother who smiled graciously. It was a brief moment in time, along a busy muddy road and yet it was something I’ll never forget.

Sure enough these experiences bring into stark relief the comfort and privilege of my own life. I feel so fortunate to have had the experiences in my life that have led me to this point. I can’t express my gratitude enough for all of my wonderful memories. Life is hard here, but people are joyful. They are quick to return a smile, easy to laugh, carry wisdom in their eyes. Life happens here because of people, not in spite of them. So, in honour of those people, I will continue to flash my big goofy grin, clasp my hands at my chest, Namaste and bow. And I will continue to tell stories and to reflect on my own memories to process everything that goes on here. It is different, to be sure, but it is lovely.

**Side note: should you not hear from us for a few days, fear not! We’ll be travelling to Pokhara and won’t have quite so easy access to the internet there. We’ll remain there until May 2, at which point we will head to Jomsom to begin a workshop and teaching trek, where we very likely won’t have any internet at all. We aim to be back in Kathmandu on May 19. We will be reflecting on our thoughts likely with pen and paper and may transcribe those thoughts onto the blog during flights between destinations once our travels here come to a close.

Day two of our travels in Nepal was fabulous. We had a chance to walk around some more and work on some MIDSON documents through the afternoon. In the early evening we headed out to Boudhnath Stupa, where one is to walk in circles and spin the prayer wheels to send up blessings for all sentient beings. You always walk with the temple on your right, and then spin the wheels with your right hand. Prayer flags adorned this temple and monks were walking as much as locals and tourists were. The temple itself is white with a gold centre mount, and eyes painted on looking in all four directions. It seems to be a fairly iconic place given that it also graces the cover of my Lonely Planet guidebook!

After our walk, and spinning of prayer wheels, we met up with our trekking guide, Bishnu to discuss plans for our trek and workshops that we’ll be doing in the Upper Mustang region in May. Bishnu was an absolute delight! He speaks perfect English and is obviously a very competent trekking guide. We thoroughly enjoyed every minute, while watching the light fade over the temple. We were so energized by the plans for our trek and workshops en route! It was a very fun night.

By Day three, we were starting to feel a bit laggy. We had a slow morning, complete with delicious breakfast once again and then headed out to visit some more of the movers and shakers in the midwifery world here in Nepal. We met with Sister Rashmi, another instrumental member of MIDSON and birth centre guru. She and another wonderful nurse and Ph.D. candidate, Laxmi spoke to us about midwifery in Nepal, its absence here and a plan for education and improving outcomes. Sister Rashmi talked about the difficulty of having a birth centre in a location where women and families think doctors are the appropriate practitioners for birth, in an area saturated with hospitals. Laxmi spoke of the need for a mindset change amongst the Nepali people to improve birth outcomes here and support the development and growth of midwifery. They made very clear the need, and special focus on reducing intervention and increasing physiologic birth by supporting things as simple as delayed cord clamping. This meeting was an excellent precursor to our upcoming work in Pokhara, as it really helped set the stage for both Rachelle and I as to where midwifery is currently in Nepal and what birth is typically like in hospital here, by comparison with the lovely birth we witnessed at the Teaching Hospital Birth Centre on Sunday.

While at the community birth centre with Sister Rashmi and Laxmi, we also met our very first male midwife, Patrick! He hailed from Sweden and is here for his seventh time. He is working with Laxmi and Sister Rashmi to put data together on the success of the care provided at the community birth centre, to help obtain and maintain funds that support that birth centre. Additionally, he’s also very well-versed on the role of midwives in Sweden. So for quite a while, in Kathmandu, we found ourselves discussing the similarities and differences of the roles of midwives in Sweden versus those in Canada. It made for a very interesting afternoon. Our brains were carefully cataloguing information from the stories we were being told, while our hearts were full from the love and laughter present throughout the afternoon.

This was an incredibly memorable day for both Rachelle and I. After we returned, Cathy was able to help us fill in some of the blanks around the who’s who of midwifery in Nepal. The most important take-home message is that there truly aren’t any midwives in Nepal, there are nurses with midwifery training, but the push is on for direct-entry midwives who practice full scope care in urban and rural settings. And the silver lining is that while there aren’t any “registered midwives” at present, there are wonderful nurses like Sister Rashmi with decades of experience who practice midwifery in its truest form, here in Nepal.